Prior Authorizations A Providers Perspective What Well Be Talking - - PowerPoint PPT Presentation

Prior Authorizations

A Provider’s Perspective

What We’ll Be Talking About

• History
• Present Day (12/15/14 – Today)
• The Future
• Best Practices

Alert Ambulance History

Founded in 1972, Alert Ambulance Service is a family owned and operated Ambulance company that specializes in providing unmatched quality medical transportation.

Alert Ambulance History

Nearly 20 years ago, Alert Ambulance Service partnered with Meridian Health, one of New Jersey’s largest hospital networks

Alert Ambulance History

• Leadership
• Compliance
• Active Participation
• Consensus Building

Ambulance Payment Data

• $583 Billion in 2013
• Ambulance Services: 6 Billion or only about 1%
• So Why Does Our 1% Matter to CMS so Much?
• ↑ 35% in Number of Patients Requiring Transport
• ↑ 70% in Number of Ambulance Transports
• ↑ 100% in Number of NE BLS Suppliers!
• ↑ ↑ ↑ 300% Number of Dialysis Transports!!!

Dialysis Payment Data

• New Jersey, South Carolina and Pennsylvania; 3 of the highest

dialysis related transports and inappropriate billings for NE Transports

• 2012 – 6.7M BLS NE trips to Medicare; nearly 50% were for

Dialysis (3.2M)

• 2012 – $575M paid for NE BLS trips to and from Dialysis

CMS’s Response to the Problem:

1. Increased Enforcement Activity 2. Reductions in Fee Schedule 3. Cap on Covered Trips 4. Prior Authorizations 5. Bundled Payments?

Ignorance is Bliss

Three problems that led us to where we are today

• 1. My PCS was signed by a doctor…that’s good enough,

right?

• 2. They’ve been paying me all this time…I must be

doing it the right way?

• 3. My patient can’t transfer to the dialysis chair

without 2 people assisting.

Previous Prior Authorization Pilots

• Power Mobility Device Demonstration
• Launched in 2012 - 7 States
• In 1st year, monthly claims reduced from $12M to $4M
• Extended to 12 additional states in 2014
• Estimated $740M reduction in spending over 10 years
• Set to expire September 2015
• Non-Emergency Hyperbaric Oxygen Therapy
• Launched in 2015 – 3 States
• DME, Prosthetic, Orthotic & Supply Items
• Awaiting final rule

Present Day – The Announcement

Announced on CMS.gov on 5/22/14

• Just after 2012 Part B Provider Data release which led

to increased media coverage of fraud and abuse.

• Section 1115A of the Social Security Act – Innovative

Payment & Service Delivery Models

• Piggybacked on success of the Power Mobility Device

Demonstration

• “Prior authorization will not create new clinical

documentation requirements. Instead, it will require the same information necessary to support Medicare payment, just earlier in the process.”

• Affirmed Transports Will Not Be Subjected to Post

Payment Review

Present Day – Build Up to the Start Date

• CMS, Novitas, AAA and MTANJ
• Conference Calls
• Webinars
• Meetings
• Some Providers – Preparations Begin
• Other Providers – Complaints
• Mid November 2014 – Putting it All Together

December 15th, 2014

• Actually…December 1st, 2014
• Warm up your fax machines…here it comes!
• Denials, Denials and more Denials
• Meetings, Phone Calls and more Meetings
• “Patients Are Going to Die!”

One Month In

• Providers Complaining
• Patients Suffering?
• The Sky is Falling!?
• “Oooh, Look at this…This is the first time I’ve

seen this…You’re affirmed”

Three Months In

• Three Scenarios
• Providers Shutting Down
• Providers Hanging In There
• Providers Finding Their Groove
• Dialysis Centers Refusing to Help
• “You want me…to buy a hoyer lift…???”
• The Media

Six Months In

• Two Scenarios
• Providers Shutting Down
• Providers Finding Success
• The System Seems to be Working
• Wasn’t That the Point?
• Collaborating to Find Best Practices

The Future; It’s Almost Here

• H.R. 2 – The “Doc Fix” Bill, Extension of

Ambulance Add-Ons and…

• Section 515 – Page 246 of 263 in the Bill
• 2016 – Remainder of the Jurisdiction L & 11 States
• Delaware, Maryland, North Carolina, Virginia, West Virginia

and Washington D.C

• 2017 – All Other States

Best Practices

• Rapid Identification/Rapid Assessment
• PCS Forms
• List of Helpful Documents
• Repetitive Patient Questionnaire
• How Much is Too Much?
• Homebound Dialysis Patients
• “Appealing” Non-Affirmed
• Know When to Say No

Rapid Identification & Assessment

• Call Intake
• “Routine” Priority
• “Routine Transport” Spreadsheet
• Patient Evaluators
• Limit Your Exposure
• Make the Decision
• Billing Department
• Close the Loop
• 60 Day Reminder

PCS Forms

• Go Out and Get It
• Be Nice But Don’t Accept Imperfection
• Legibility is Key
• Must be able to Prove What’s on the Form

Helpful Documents

• First…Educate the Facility
• Charting Motivation – We’re Important Too
• Legibility is Key & Name/Date on Every Page
• Minimum Data Set
• Not Every Page is Necessary
• Nurse’s Notes/Progress Notes
• Pain & Mental Status
• Therapy Notes
• Bedfast vs. Chairfast, Ability to Sit Unattended
• Recent Hospitalizations
• Consultations

Repetitive Patient Questionnaire

• Evolution of a Form
• Who Should Fill it Out
• Facility Stamp
• Attestation vs. Medical Record
• Legibility is Key & Name/Date on Every Page
• “I Certify That…”

How Much is Too Much

• It Really Depends
• Evaluator Variability
• Scrutinize Each Page
• Controlling the Narrative
• Look Out for Distractors
• Put Yourself in the Evaluator’s Shoes

Homebound Dialysis Patients

• Our Policy
• If You’re Going to Give it a Shot…
• Conversations With Care Providers
• Attestations
• Dialysis Center Charting

“Appealing” Non-Affirmed

• Prior Authorizations Not Eligible for “Appeal”
• No Limit on Resubmissions
• Find Out Who You Can Call
• Making the Call
• Engaging the Family
• “The Mayor of Hightstown”
• Cutting the ALJ Line

Know When to Say No

• Making a Hard Decision
• Dorothy H.

Case Studies

Case Study #1

Dealing with Non-Affirmed Patients

Sandra F.

• Early in the Process
• Large Stage IV Sacral Wound & Severe Dementia
• Non-Affirmed X 4
• PCS Illegible
• Paperwork Illegible
• Documentation Does Not Support Bedbound Status
• Severe Pain Only Counts When Transport >1hr!
• Fifth Time’s a Charm!

Case Study #2

Patients with a “Legal Representative Payee”

Amador D.

• Also Early in the Process
• Severe Contractures & Trach Mask w/ O2 @ 8lpm
• Non-Affirmed x 1 for Illegible PCS Then Approved
• Approved 2 More Times
• Follow-Up Letter From Novitas
• Protect Yourself – Follow the Process

Case Study #3

Finding Another Payor

James E.

• Evaluators Downgraded After Day 1
• Deconditioned
• Can’t Assist with Transfer Much But He Can Safely Sit
• Stare Down with Dialysis Center
• They Won!
• Logisticare to the Rescue
• Timing is Everything – New Jersey RFP

Case Study #4

The Boneheaded Mistake

Joyce H.

• You Name It, She Had It
• 4 Visits to the PMD’s Office
• Affirmed
• One Week Later – Patient Discharged
• Contracted Sub-Acute Rehab to Non-Contracted ECF
• Too Efficient?

More Boneheaded Mistakes

• CAD Errors
• Paperwork
• Name and Date on Every Page
• Waiting for a Reply
• 60 Days Comes Quick

Case Study #5

Steady as She Goes

Eve C.

• Severe Contractures
• Affirmed 5 Times
• New PCS and Supporting Paperwork Each Time
• Alternate Evaluators

Summary

• CMS: Prior Authorizations Work
• Participate and Prepare
• The Road Starts out Bumpy
• Bad Providers Will Fail – Not a Bad Thing
• Dedicate Appropriate Resources
• Descriptive, Clear and Legible Paperwork is Key
• Communicate With Your Association & Carrier
• Hopefully…Before Too Long…Steady as She Goes

Thank You!

John Iazzetta Director of Operations (732) 364-2856 ext. 140 John.Iazzetta@AlertAmbulance.com